Transgender Surgery of the Head and Neck

In the United States, between 0.4% and 3% of the population identifies as transgender, equating to over 1,000,000 Americans. Not every transgender individual will need or want medical or surgical treatment. Still, given the prevalence of transgender patients in the population, healthcare providers need to be aware of transgender health issues. According to the 2015 United States Transgender Survey, which compiled responses from 28,000 individuals who identify as transgender or gender non-conforming, 33% of respondents reported being mistreated due to gender identity when seeking healthcare. For this reason, healthcare providers who care for transgender patients - and this is a constantly increasing proportion of healthcare providers - must be ready to identify and provide for the needs of these patients. Simply being welcoming, accepting, and non-judgmental is an important first step in building a therapeutic rapport; having an inclusive office in which staff members are trained to ask for patients' preferred pronouns and give their own, and ideally provide gender non-specific restrooms, will make the healthcare environment substantially more trans-friendly. Transgender patients commonly benefit from behavioral health and endocrine interventions (estrogen and anti-androgen therapy for male to female transitions and testosterone for the female to male), and the World Professional Association for Transgender Health (WPATH), in its most recent Standards of Care publication (SOC 7, published in 2012), has strongly recommended that patients considering genital surgery ("bottom surgery") have not only a persistent, well-documented history of gender dysphoria but have also completed 12 continuous months of hormonal therapy preoperatively. For chest surgery ("top surgery"), either augmentation or reduction mammoplasty, the WPATH recommends patients have a persistent and well-documented history of gender dysphoria and that patients transitioning from male to female also consider 12 continuous months of feminizing hormone therapy preoperatively. There are no explicit recommendations in SOC 7 for behavioral health documentation or duration of hormonal therapy prior to head and neck surgery, which will focus on this article. With respect to gender affirmation procedures for the face, the majority of interventions will occur in patients transitioning from male to female, i.e., transgender women. While there are slightly more transgender women than transgender men in the population (33% transgender women, 29% transgender men, 35% non-binary, 3% crossdressers, according to the USTS), the reason that more females require surgery than males is that testosterone therapy typically produces enough changes in secondary sex characteristics of the face (growth of facial hair, thickening of the skin, increase in frontal bossing, lowering of the voice, etc.) that surgery is not necessary. In some cases, placement of implants or fat transfer can increase volume in the lower third of the face and contribute to masculinization. Still, the primary area of focus for facial feminization is generally the upper third. Feminization of the upper third of the face often requires several techniques to be applied in combination: the advancement of the hairline, hair transplantation, brow lifting, and reduction of frontal bossing or "frontal cranioplasty." While the advancement of a scalp flap, hair transplant, and pretrichial brow lifting are commonly-employed cosmetic surgery interventions, frontal cranioplasty bears special consideration. Several methods of reducing the brow's prominence are often described as type 1, 2, and 3 frontal cranioplasties. Type 1 cranioplasty reduces the supraorbital ridge's protrusion, usually using a drill, including decreasing the thickness of the anterior table of the frontal sinus. This technique is the simplest, but it is only effective in patients with either a very thick anterior frontal sinus table or an absent pneumatized frontal sinus. Type 2 cranioplasty involves augmentation of the forehead's convexity using bone cement or methyl methacrylate in addition to a reduction of the supraorbital ridge with a drill. Type 3 cranioplasty is advocated by many prominent facial feminization surgeons and consists of removal of the anterior table of the frontal sinus, thinning of the bone flap, and replacement of that bone onto the frontal sinus but in a more recessed position, in addition to a reduction of the remainder of the supraorbital ridge. An alternative to removal and recession of the frontal sinus's anterior table is to thin the bone with a drill and then infracture it in a controlled fashion to produce the desired contour, which is also performed routinely by some authors. Other common surgical interventions requested by transgender women include feminization of the eyes via lateral canthoplasty, reduction rhinoplasty, malar implant placement or fat transfer, upper lip lift, mandibular angle reduction, genioplasty, rhytidectomy, laser hair removal, and laryngeal chondroplasty ("tracheal shave"). Because of the breadth of procedures often performed during gender affirmation of the head and neck, it is advisable to employ a multidisciplinary model for delivering patient care, in which a plastic surgeon or facial plastic surgeon may perform the brow and scalp surgery as well as the lip lift, rhinoplasty, implant or fat placement, and/or rhytidectomy; an oral surgeon may provide the mandibular angle reduction and genioplasty; an ophthalmologist or oculoplastic surgeon may perform the canthoplasty; a laryngologist or otolaryngologist may offer laryngeal chondroplasty or voice feminization surgery, and a dermatologist may provide laser and injectable treatments. Beyond the procedure-oriented physicians, however, it is critical to remember the roles of endocrinologists or primary care providers and behavioral health providers on the team because they will often provide longer-term continuity of care for transgender patients.